K:\My Documents\Cases\Guidant\Court Filings\Complaint ... - BNA

CASE 0:11-cv-00022-DWF -AJB Document 45 Filed 01/27/11 Page 10 of 35C. The Federal Medicare Program36. In 1965, Congress enacted Title XVIII of the Social Security Act, 42 U.S.C.§ 1395 et seq., known as the Medicare program. Entitlement to Medicare is based on age,disability, or affliction with end-stage renal disease. 42 U.S.C. §§ 426, 426A. Medicare isadministered by CMS, which is part of the Department of Health and Human Services. Atall times relevant to this Complaint, CMS contracted with private contractors referred to as“fiscal intermediaries” and “carriers” to act as agents in reviewing and paying claimssubmitted by health care providers. 42 U.S.C. § 1395h; 42 C.F.R. §§ 421.3, 421.100.37. For inpatient treatment, reimbursement to treating facilities (such as hospitals)is governed by Medicare Part A, 42 U.S.C. §§ 1395c-1395i-5. For outpatient treatment,reimbursement to health care providers (such as doctors) is governed by Medicare Part B,42 U.S.C. §§ 1395j-1395w-4.38. To obtain Medicare reimbursement, providers submit claims using forms(known as CMS 1500s for outpatient claims and UB-92 or UB-04 for inpatient treatment).Providers identify by code on the appropriate form, among other things, the principaldiagnosis of the patient and the procedures and services rendered.39. Under the Medicare program, “no payment may be made under part A or partB for any expenses incurred for items or services which . . . are not reasonable and necessaryfor the diagnosis or treatment of illness or injury or to improve the functioning of themalformed body member.” 42 U.S.C. § 1395y(a)(1)(A).10